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Eur J Cardiothorac Surg 2004;25:1059-1064
© 2004 Elsevier Science NL
a Clinic of Thoracic Surgery, National Tuberculosis and Respiratory Diseases Institute, Krajinska Street No. 91, 825 56 Bratislava, Podunajske Biskupice, Slovak Republic
b Department of Pathology, Comenius University of Bratislava, Bratislava, Slovak Republic
c Department of Bronchoscopy, National Tuberculosis and Respiratory Diseases Institute, Bratislava, Slovak Republic
Received 13 October 2003; received in revised form 16 January 2004; accepted 16 February 2004.
* Corresponding author. Tel.: +421-907-127-697; fax: +421-2-452-436-22
e-mail: arpad_pp{at}hotmail.com
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Abstract |
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 Top Abstract 1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Key Words: Endotracheal stenting • Tracheal reconstruction surgery • T-tube • PostTS, Posttracheostomic tracheal stenosis • PostINT, Postintubation tracheal stenosis • T-Efist, Tracheo-esophageal fistula
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1. Introduction |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Management of obstructive tracheal laesion, which develops as a result of long-term intubation, is a complex problem, which requires individual approach. Fully developed stenotic laesion with a high degree of obstruction, which is manifested certain time later after extubation, requires radical surgical resection. As it is known, it is not always feasible [2,4]. The number of complicated tracheal laesions, where its resection and anastomosis are not successful or not applicable, increases and the situation requires solution by endoprosthesis [2,5,6]. Among the large number of endoprosthesis applicable for tracheal stenting a significant place belongs to the T shaped tubes [7,8].
The main goal of this paper is to review the single institution experience with tracheal stenosis treatment and to define a role of endotracheal stenting in tracheal reconstruction surgery. This paper presents retrospective analysis of tracheal stenosis reconstruction by a modified Montgomery T-tube invented in our Clinic.
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2. Patients and methods |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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There were 114 males and 49 females in age range from 0.5 to 79 year (mean 43.2 years).
Indications for reconstruction were: posttracheostomic (PostTS) and postintubation (PostINT) stenoses in 111 cases/i.e. PostTS, n=72; PostINT, n=34; mixed: n=5, tumor-stenosis in 24 cases, tracheo-esophageal fistulas (T-Efist) in 17 cases, traumatic laesions in six and functional stenosis in five cases (Fig. 1) . For these indications, the following procedures were performed: primary suture of traumatic tracheal wall was performed in five cases, laser intervention and tumor resections in three cases, segmental tracheal resection in 87 cases, and stenting in 68 cases. From among these 68 cases, 65 were solved by our own modification of Montgomery T-tube. That is why this retrospective analysis focuses on these above-mentioned 65 patients (Table 1).
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Indications for T-tube insertion were: PostTS in 27 cases, PostINT in 7 cases, mixed (PostTS+PostINT) in 4 cases, tumors in 17 cases, T-Efist in 7 cases, functional stenoses in 3 cases.
2.2.3. Procedures
The group of T-tube patients is not homogeneous. It contains patients with benign tracheal diseases (n=46), with malignancies (n=19)/i.e. 17 patients with tracheal tumors and 2 patients with malignant T-Efist (Table 1).
In accordance with our standard indication criteria (Table 2) the T-tube was inserted as:
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3. Results |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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3.1. Benign tracheal stenoses
3.1.1. Posttracheostomy tracheal stenoses (n=22)
From the total group of 22 patients/11 females and 11 males with mean age of 44.8 years (15–77 years), 50% of patients were already successfully extubated within 3 to 90 months. The second half of patients is still wearing the T-tube (time period from 2 to 118 months). These patients are constantly followed, their prognosis differs, some of them are candidates for extubation.
3.1.2. Postintubation tracheal stenoses (n=7)
From the total group of 7 patients/2 females and 5 males with mean age of 57.7 years (42–72 years), 71% (n=5) of patients were freed from the T-tube within 2 to 18 months. One patients is still wearing the T-tube for 14th month, and one patient who wore the tube for 24 months died on heart failure.
3.1.3. Functional stenoses (n=3)
We inserted the T-tube to a 21 year old patient with relapsed polychondritis with a long-term tracheostomy 18 months ago. Nowadays, he still wears the T-tube, undergoes regular check ups at our outdoor patients department.
The other 69 year old male patient was admitted to our department from the otorhinolaryngologists' with his diagnosis of osteoplastic tracheopathy. The patient immediately underwent longitudinal discission of tracheal front wall and granulation extraction. The T-tube then was inserted through tracheofissure tracheal opening. The patient is still wearing the T-tube and undergoes regular check ups at our outdoor patients department.
The case of the third 63 year old female patient with functional tracheal stenosis will be described detailly below (in Section 3.3) as a case of tracheal rupture immediately after the Dumon stent application.
It is important to underline that the group of patients with functional stenosis is not a homogeneous one, it includes several different diagnoses and we placed all of these cases together only from the schematic point of view.
3.2. Malignant tracheal stenoses
3.2.1. Non-resectable tumors, malignancies (n=19)
This group includes 2 patients with malignant T-Efist and 17 patients with non-resectable malignant tumors, which caused tracheal stenosis.
The prognosis of these patients is dependent on the degree of advancement of their malignant disease. Due to its nature in most cases it is not favorable. The patients are being treated in local oncological departments in the region of their residence according to the progression of their disease.
The 2 patients with malignant T-Efist were male, aged 59 and 68 years. The histology of their underlying diseases were squamos cell esophageal cancer and malignant lymphoma, respectively. They both died two and three months after the intervention.
In the group of 17 patients there were 7 patients with malignant goiter and 10 patients with other (primary and secondary) malignancies.
In all cases with malignant goiter the indication for urgent surgical intervention was primarily to ensure patency of the upper respiratory ways, secondarily to gain histologization of tumors. All these patients underwent tracheofissure, discission of tracheal front wall, insertion of T-tube. In all cases it was an advanced malignant tumor where the radical surgical resection was not feasible. Four patients had already had pulmonary metastases in the time of tracheal intervention. From the total of seven patients we lost 3 patients to follow-up, the mean survival of the rest four patients is 4.8 months. Demographically this group consisted of 3 females and 4 males with the mean age of 61 years.
The remaining 10 cases involved: 3 cases with tracheal adenocarcinoma, 2 cases with tracheal squamos cell carcinoma, 2 cases with mediastinal malignant lymphoma, 2 cases with osephageal (laryngeal) spinocelular carcinoma and the last 1 case with metastasis of Grawitz tumor. Demographically these 10 cases are: 3 females, 7 males with a mean age of 59.4 years (45–69 years). The mean survival for the above patients were 3.5 months.
Finally, we can only state that the results in treatment of such patients with malignancies, where the radical surgical intervention cannot be performed, are burdened with high mortality rate. However, we believe, that to ensure respiratory ways by a T-tube and thus to make patient's quality of life better, is very important. We also must not forget the fact that recently the number of such patients is increasing.
3.3. Follow-up of T-tube bearers, observation of tracheal mucous membrane reaction to T-tube
It follows from the above-mentioned, that from among 51 patients who received T-tubes within single procedure, 15 patients are still under our regular follow-up. Their diagnosis are: 3 patients with functional tracheal stenosis, one with postintubation and 11 patients with posttracheostomic tracheal stenosis. The follow up period of T-tube wearing ranged from 2 to 118 months (mean 46.1 months). Our regular record of check ups were reduced by 19 patients with malignancies (death), and by further 17 patients (PostTS and PostINT), who were already successfully extubated and released.
During the regular check-ups of T-tubes patients, besides other activities we also removed biopsies from the tracheal mucous membrane and studied the reaction of mucosa on endoprosthesis. During the stenting procedure by any type of endoprosthesis there was no evidence of creation of a full-valued, original respiration epithelium. Only metaplastic changes of mucous layer could always be seen, no matter which type of endoprosthesis was used. This metaplasis was created by squamous cells with their hyperplasy, however, without dysplasia. On the surface layers parakeratosis was found; the top layers were usually covered by a film that contained polymorphonuclears. Lamina propria layers are always infiltrated by chronic inflammatory infiltrate. We can always observe these changes, but they were found most considerable after trachea stenting by metallic endoprosthesis.
In all kinds of trachea reconstruction a relatively good toleration of silicone material was observed. Silicone T-tube causes minimal complications. Obstruction of T-tube by dense sputum, which required the T-tube removal and is replaced by a double-coated tracheostomy tube, was the most common complication. The location, where most complications occurred was the upper part of the T-tube, in the place from where it was inserted to subglottic area. Here, irritations and granulations could be sporadically observed. It is really difficult to estimate the correct length of the upper end of the T-tube's vertical branch. For this reason it was necessary to perform endoscopic checks with the adjustment of the tube's upper end (due to the close position of vocal cords, and due to a necessity of granulations' overbridging). After insertion of the T-tube's upper vertical part through vocal cords and its long-term positioning in this area, significant changes of vocal cords were not observed. After the removal of the tube, the patient's voice spontaneously appeared, even though it was not always clear.
3.4. Results of other endoprosthesis stenting
In order to complete this chapter, results after stenting by other traditional endostents will be briefly described. This stenting was performed in 3 patients: i.e. the dynamic tracheobronchial stent was inserted in 2 cases, and the Dumon stent was inserted to one patient (Table 1).
The tracheobronchial stent was applied to the 60 year old male patient with malignant T-Efist (squamous cell esophageal carcinoma). The patient tolerated the stent very well, the respiratory ways were ensured this way very well, too. This patient, however, died 6 months later due to progression, generalization of his malignant disease.
In another case this stent was inserted to a 40 year old male patient with a compressive, extramural tracheal stenosis caused by mediastinal tumor (originally histological leiomyoma). For its aggressive pressing attributes we were forced to perform a right-sided pneumonectomy and change the original stent for another one with its shorter right and upper-vertical branch. The patient died a month later due to the expansive character of the tumor (pressing of great vessels and cardiac arrest), the histology of tumor was re-classified as a leiomyosarcoma.
The Y-shaped Dumon stent was applied to a 63 year old female patient with functional tracheal stenosis. As this insertion was complicated by tracheal rupture, an urgent right-sided thoracotomy with stent extraction and coverage of the rupture by pleuromusculoperiostal flap, followed by T-tube stenting were performed (Table 1).
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4. Discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Among numerous types of endoprosthesis the best ones, which were proven by time, are made of silicone [10,11]. In our study our own modification of Montgomery silicone T-tube was used [9]. Its greatest advantage is that this T-tube serves as an internal stent as well as a tracheostomic tube. Its smooth and non-immerse surface restricts the mucous sputum adherence and incrustation creation.
It has to be said that the silicone gum material is so far the best material for temporary tracheal stenting. It is rigid enough to restrict the narrowing of tracheal lumen during the granulation tissue maturation, and in the other hand it is fine (smooth) enough to allow the tracheal epithelium growth through granulations [9,12]. The therapy of stenting is time-consuming. The period of time necessary for trachea wall stabilization and trachea mucosa healing differs from case to case, that is why the time of wearing the T-tube by our patients was different. In our study the mean time to wear the T-tube is 26.4 months (including patients with permanent T-tube).
In the end phase of tracheal reconstruction we perform our own original technique of tracheoplasty using perforated autologous rib cartilage [2]. Silicone T-tube was applied to 65 patients; to patients with benign tracheal stenoses in 46 cases, to patients with malignant disease in 19 cases. The mean age of those patient was 49 years.
The success of treatment by T-tube is given by safeness of this modality. Silicone T-tube is more safe than any other endoprosthesis, because it creates a smooth regenerated surface and there is a great probability of extubation or possible resection, respectively. As it was already described above, our T-tube mainly differs from the Montgomery one by its horizontal branch, which is wider and vertically oval-shaped (Fig. 2). There are several advantages of this modification, they are detaily described in the paragraph above (T-tube).
In our study management of posttracheostomic and postresection tracheal stenosis, and also tracheo-esophageal fistula stenosis by T-tube, where the previous efforts for reconstruction failed, was the most successful. We mainly appreciated the advantages of stenting by T-tube in those cases, where the segmental resection is not feasible or its too risky. In special situations T-tube is the most effective solution: it enables verbal communication to the patient, allows natural ventilation (per vias naturales) and over-bridges the periods necessary for a definite tracheal stenosis solution. Besides incomparably better comfort for the patient, it ensures an effective stenting of respiratory ways.
Additionally this study allows to compare the group of 87 patients after radical segmental resection with a group of 65 patients after T-tube stenting. It is evident from the data that the success of segmental resections is higher than it is after conservative treatment. Segmental tracheal resection (n=87) was successful in almost all cases (96%). Eighty-four patients left the hospital in good condition, their tracheal stenoses were definitely solved by all the mentioned procedures. In three patients re-resection in early postoperative period was necessary. After that their further postoperative course was uneventful.
Only 41.6% of patients after conservative treatment (n=65) can be classified as success, i.e. the T-tubes were successfully removed in 27 cases. (In 19 patients (29.2%) the stenting is still continuing, but they are candidates for tube extraction in the near future. In 19 patients (29.2%) with malignancies the T-tube was applied only as a palliation. All of these patients died.)
It must be emphasized that in the group of patients managed by the T-tube the success rate is evidently smaller, but despite this treatment modality it often remains the only possible solution for patients in apparently deadlock situations.
As it was emphasized in the Introduction (Section 1) already, tracheal stenosis is a serious disease with increasing tendency. Among this increased number of tracheal stenosis complicated, multi-segmental, long stenoses can be found. Also there is an increasing number of patients with non-resectable tumors and patients after segmental tracheal resection with a developed anastomotic insufficiency. In such cases, dramatic situations, the only optimal solution is to use a conservative way with T-tube stenting.
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Footnotes |
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Appendix A. Conference discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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Dr. Pereszlenyi: As I was given only 5 minutes for this presentation, I mainly wanted to focus on the stenting by our own modification of the Montgomery T-tube. In the written paper you can find a whole chapter on complications also during the learning curves as well as on the T-tube patients' follow-up period. As it is known, stenting procedure with the T-tube is time consuming, also due to the fact that each patient had to be treated individually, accurately with periodical checks in the follow-up period.
Dr. W. Weder (Zurich, Switzerland): You observed 111 postintubation tracheal stenoses. This is an enormous number. Don't you use low-pressure tubes in your country?
Dr. Pereszlenyi: In my country the indications, the vast majority of the mentioned 111 cases, underwent procedures at the very beginning of 1990s, and that time we had no low-cuff tracheostomy tubes. And I have to clarify again that these 111 patients were of both: posttracheostomic and postintubation stenoses, i.e. 111 were not only postintubation stenoses. There was also a large group of posttracheostomic ones.
Dr. Weder: But in 10 years, also after tracheostomy, what kind of technique of tracheostomy do you use that you have such a high number of stenoses thereafter?
Dr. Pereszlenyi: All these patients (total - 163) were referred to our institution, our clinic from all around Czechoslovakia, and after the division - Slovakia. So, it means that the vast majority of the cases were not from our hospital (we were only solving the complications originated elsewhere). I participated in the Slovak National Anesthesiology Congress and discussed the topic on the problems related with performing of tracheostomy.
Dr. T. Orlowski (Warsaw, Poland): It should be stressed also that sometimes this is the result of the laser usage which enlarges the segment of the stenosis.
Dr. G. Friedel (Gerlingen, Germany): You have a large group of patients who were treated preoperatively by T-tube. I don't really understand these cases. Why do you treat them preoperatively?
Dr. Pereszlenyi: The group of patients, where the indication for T-tube application was preoperatively performed, involves a lot of different diagnoses, a lot of different indications. Also, there are patients in bad condition, intubated, who are not able to cooperate. But the condition of some of them after the successful intensive care management improved to such level that the segmental tracheal resection became feasible.
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References |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionAppendix A. Conference...References |
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This article has been cited by other articles:
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  C.S. Pramesh and R. C. Mistry Management of pediatric airway obstruction J. Thorac. Cardiovasc. Surg., January 1, 2006; 131(1): 253 - 254. [Full Text] [PDF]
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 C.S. Pramesh, R. C. Mistry, and V. V. Upasani Stents and sensibility--use of the Montgomery T-tube in tracheal stenosis Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 1060 - 1060. [Full Text] [PDF]
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A. Pereszlenyi, M. Igaz, I. Majer, and S. Harustiak Reply to Pramesh et al. Eur. J. Cardiothorac. Surg., November 1, 2004; 26(5): 1060 - 1061. [Full Text] [PDF]
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